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160
Fig. 12.18 The mesh is pulled tightly against the abdominal wall
J. T. Watson and K. A. LeBlanc
Fig. 12.20 Second row of sutures on the opposite side of
the intestine (yellow arrows indicate the inner row of
suture near intestine; light blue indicates the outer row of
suture)
Fig. 12.19 Fascial xation of one side of the mesh (yellow arrows indicate the inner row of suture near intestine;
light blue indicates the outer row of suture)
This is a double-armed suture. One arm will run
adjacent to the intestine and the other near the
edge of the mesh (Fig.12.19). A second doublearmed and barbed suture will be used to suture on
the side opposite the initial one next to the intestine and the other arm on the lateral aspect of the
mesh (Fig.12.20). This will create the tunnel for
the intestine to enter, as is typical of the
Sugarbaker repair. The nal step is to suture the
mesh to the intestine with a smaller barbed
polydioxone suture similar to the laparoscopic
technique. This results in a repair that is reliable
(Fig.12.21).
Postoperative Management
Abdominal binders are generally not used, as this
seems to interfere with ostomy function. The
nasogastric tube and urinary catheter are removed
Fig. 12.21 Completed robotic parastomal hernia repair
on postoperative day one. Meals are advanced as
appropriate. Patients are usually discharged on
the second or third postoperative day.
Most of these hernias will develop a seroma.
Generally they are small unless the hernia contents were long standing and of large amount.
Patients should be informed of such preoperatively. Unless very symptomatic no treatment is
necessary. If needed, aspiration or drainage via
interventional radiology could be done.
Results
To date, we have performed 16 parastomal hernias using the robotic assistance. At the time of
this writing, the follow-up ranged from 6 to
42months. One patient early in this experience
did have to be returned to the operating room due
to an obstruction that was caused by suture that
12 Parastomal Hernia Repair
161
xed the mesh to the anterior abdominal wall.
The mesh was slit and re-sutured to the intestine.
There have been no other adverse events or recurrences during this time frame. It now has become
our preferred method of repair.
Conclusion
The laparoscopic repair of parastomal hernias
is a preferred technique over the open method.
This can be done in a safe and effective manner with the Sugarbaker or the modied
Sugarbaker, as described in this chapter. The
robotic repair is an extension of that repair and
should provide similar, if not, superior results.
References
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D, Bury K, Conze J, Hansson B, Janes A, Miserez
M, Mandala V, Montgomery A, Morales Conde S,
Muysoms F. European Hernia Society classication
of parastomal hernias. Hernia. 2014;18(1):1–6.
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Navarro-Soto S. The prevalence of parastomal
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8. Kroese LF, de Smet GH, Jeekel J, Kleinrensink GJ,
Lange GF. Systematic review and meta-analysis of
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9. Janes A, Cengiz Y, Israelsson L.Preventing parastomal hernia with a prosthetic mesh: a 5-year follow-
up of a randomized study. Ann R Coll Surg Engl.
2009;93(2):118–21.
10. Tam KW, Wei PL, Kuo LJ, Wu CH.Systematic review
of the use of a mesh to prevent parastomal hernia.
World J Surg. 2010;34(11):2723–9.
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reviw on the use of prophylactic mesh during primary
stoma formation to prevent parastomal hernia formation. Color Dis. 2012;14(8):931–6.
12. Williams NS, Hotouras A, Bhan C, Murphy J,
Chan CL. A case-controlled pilot study assessing
the safety and efcacy of the Stapled Mesh stomA
Reinforcement Technique (SMART) in reducing the incidence of parastomal herniation. Hernia.
2015;19(6):949–54.
13. Ng ZQ, Tan P, Theophilus M.Stapled Mesh stomA
Reinforcement Technique (SMART) in the prevention of parastomal hernia: a single-centre experience.
Hernia. 2017;21:469–75.
14. Brandsma HT, Hansson BM, Aufenacker TJ, van
Geldere D, Lammeren FM, Mahabier C, Makai P,
Steenvoorde P, de Vries Reilingh TS, Wiezer MJ, de
Wilt JH, Bleichrodt RP, Rosman C.Prophylactic mesh
placement during formation of an end- colostomy
reduces the rate of parastomal hernia: short-term
results of the Dutch PREVENT-trial. Ann Surg.
2017;265(4):663–9.
15. Jänes A, Cengiz Y, Israelsson LA. Preventing parastomal hernia with a prosthetic mesh: a 5-year
follow-up of a randomized study. World J Surg.
2009;33(1):118–21.
16. Warwick AM, Velineni R, Smart NJ, Daniels
IR.Onlay parastomal hernia repair with cross-linked
porcine dermal collagen biologic mesh: long-term
results. Hernia. 2016;20(2):321–5.
17. Safadi B.Laparoscopic repair of parastomal hernias:
early results. Surg Endosc. 2004;18:676–80.
18. Hansson BME, Bleichrodt RP, DeHingh
IHJT. Laparoscopic parastomal hernia repair using
a keyhole technique results in a high recurrence rate.
Surg Endosc. 2009;23:1456–9.
19. LeBlanc KA, Bellanger DE, Whitaker JM, Hausmann
MG.Laparoscopic parastomal hernia repair. Hernia.
2005;9:140–4.
20. LeBlanc KA.Mesh overlap is a key determinant of
hernia recurrence following laparoscopic ventral and
incisional hernia repair. Hernia. 2016;20(1):85–9.
21. P W, Andersen LM. Long-term follow-up
of laparoscopic repair of parastomal hernia
using a bilayer mesh with a slit. Surg Endosc.
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A. The Achilles’ heel of Sugarbaker. Hernia.
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23. Liu F, Li J, Wang S, Yao S, Zhu Y.Effectiveness analysis of laparoscopic repair of parastomal hernia using
CK Parastomal patch. Zhongguo Xiu Fu Chong Jian
Wai Ke Az Zhi. 2011;25(6):681–4.
24. Mizrahi H, Bhattacharya P, Parker MC.Laparoscopic
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25. Berger D, Bientzle M.Laparoscopic repair of parastomal hernias: a single surgeon’s experience in 66 cases.
Dis Colon Rectum. 2007;50(10):1668–73.
26. Berger D, Bientzle M.Polyvinylidene uoride: a suitable mesh material for incisional and parastomal hernia repair. A prospective observational study of 344
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27. Mancini GJ, McClusky DA 3rd, Khaitan L,
Goldenberg EA, Heniford BT, Novitsky YW, et al.
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28. McLemore EC, Harold KL, Efron JE, Laxa BU,
Young-Fadok TM, Heppell JP. Parastomal hernia:
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29. Craft RO, Huguet KL, McLemore EC, Harrold
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30. Hansson BM, Slater NJ, van der Velden AS,
Groenewoud HM, Buyne OR, de Hingh IH, Bleichrodt
RP.Surgical techniques for parastomal hernia repair.
Ann Surg. 2012;255(4):685–95.
31. DeAsis FJ, Lapin B, Gitelis ME, Ujiki
MB.Current state of laparoscopic parastomal hernia repair: a meta- analysis. World J Gastroenterol.
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32. Bittner R, Bingener-Casey J, Dietz U, Fabian
M, Ferzli G, Fortelny R, et al. Guidelines for
laparoscopici treatment of ventral and incisional abdominal wall hernias (International
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2014;28(2):380–404.
Postoperative Management
(Routine andComplex Situations)
ShirinTowgh andDesmondT. K.Huynh
13
The various incisional hernia repair techniques
are essentially the same in concept, whether performed via open, laparoscopic, or robotic
approaches: The defect is cleared of its content,
and it is closed or patched with a mesh implant.
However, with regard to postoperative management, there are specics to the laparoscopic and
robotics approaches that should be appreciated.
The enhanced recovery after surgery (ERAS)
pathway applies to all approaches. Steps that may
be unique to the laparoscopic vs. robotic
approaches are (a) the size of the trocars, cannulas and their placement, (b) the manipulation of
the abdominal wall, (c) handling of the abdominal contents, and (d) the placement options for
the mesh implant. Based on these factors, postoperative management may be slightly different
when handling patients who undergo laparoscopic vs. robotic repair.
Enhanced Recovery After Surgery
The enhanced recovery after surgery (ERAS)
pathway for hernias is validated and should be
followed to reduce postoperative morbidity and
S. Towgh (*)
Beverly Hills Hernia Center, Beverly Hills, CA, USA
e-mail: DRTOWFIGH@BeverlyHillsHerniaCenter.com
D. T. K. Huynh
Cedars-Sinai Medical Center, Los Angeles, CA, USA
length of stay [1]. It is a multifaceted approach
aimed at reducing infections, improving pain
control, and maximizing healing potential.
Table13.1 demonstrates the essential elements of
the ERAS pathway for hernias. There is a more
in-depth discussion on this in Chap. 3.
The ERAS pathway for hernias is most applicable to open abdominal wall reconstruction.
This is especially true with regard to the diet,
which is slowly advanced over a matter of days.
After laparoscopic incisional hernia repair, especially with intraperitoneal mesh placement, ileus
can be a signicant problem. It is estimated that
20% will have a postoperative ileus beyond
24 hours and 1.3% may have it last beyond a
week [2]. There seems to be no predictable risk
factors for prolonged ileus, though there is a positive correlation with the amount of dissection,
size of mesh, and excess use of postoperative
opioids.
In contrast, for most robotic incisional hernia
repairs, the patient may start on a regular diet
immediately or by postoperative day 1. It is postulated that robotic repair causes a lower ileus
rate because the mesh is often placed extraperitoneally, the abdominal wall and intestine are minimally manipulated, and there is overall lower
postoperative pain.
The multimodal pain therapy from the ERAS
pathway is excellent and should be followed for
all approaches. In most situations, the robotic
approach will not require IV pain medication,
© Springer International Publishing AG, part of Springer Nature 2018
K. A. LeBlanc (ed.), Laparoscopic and Robotic Incisional Hernia Repair,
https://doi.org/10.1007/978-3-319-90737-6_13
163
164
S. Towgh and D. T. K. Huynh
Table 13.1 Postoperative elements of ERAS for incisional hernias [1]
Multimodal pain control
TAP block
Patient-controlled analgesia
Acetaminophen
Oxycodone as needed
Gabapentin
Valium as needed
NSAIDs
Acceleration of intestinal recovery
Alvimopam
Early feeding
POD 0: Limited clear liquids
POD 1–2: Clear liquids
POD 3: Regular diet
ERAS enhanced recovery after surgery, TAP transversus
abdominis plane, PO by mouth, NSAIDs nonsteroidal
anti-inammatories, POD postoperative day
patient-controlled analgesia, or valium, as the
length of stay is expected to be low (see “The
Abdominal Wall” below).
Trocars andCannulas
Laparoscopic trocars come in various diameters
and insertions. Some are threaded; others have
balloons tips. Insertion can be blunt, radially
spreading, or sharp. The resulting fascial defect is
highly variable depending on the type of trocar.
We know that the typical 5, 10, 11, and 12mm
trocars have a signicantly wider outer diameter
than advertised (Table 13.2). Also, the fascial
defect may be related to body habitus as well as
the trauma inicted on the abdominal wall at the
time of operation.
The incidence of port-site hernias during laparoscopy ranges from 0.65 to 2.80% [3]. It is lower
in the morbidly obese. Port-site hernias have
been reported for all sizes of trocars used, though
the prevalence is higher with larger port sites.
One method to reduce the risk of herniation is to
skive the trocar through the abdominal wall in
such a way as to reduce the amount of tension
during each particular operation. For example,
for repair of a midline incisional hernia, one may
consider entering the lateral abdominal wall at an
Table 13.2 Variable width dimensions of the laparoscopic ports
Outer diameter
5mm
trocars
≤9.7mm ≤14.2mm ≤15.9mm ≤19.1mm
Table 13.3 Width dimensions of the robotic cannulas
Outer diameter
Si 10.48mm 13.39mm
Xi 9.75mm 15.20mm
11mm
trocars
8mm cannula 12mm and Stapler cannulas
12mm
trocars
15mm
trocars
angle toward the hernia defect, thereby reducing
the amount abdominal muscle spreading at the
site of the trocar during the hernia manipulation.
The da Vinci (Intuitive Surgical, Sunnyvale,
CA) robotic cannula sizes used today for abdominal wall operations are typically 8mm or 12mm.
The body of the cannulas is made of strong stiff
metal. Their obturators may be blunt or sharp.
Unlike most laparoscopic trocars, the robotic
cannulas are introduced perpendicular to the
abdominal wall; skiving is not recommended.
Similar to laparoscopic trocars, the outer diameter of the robotic cannulas is wider than the noted
cannula size (Table13.3).
There have been a few articles addressing
port-site hernias specically after robotic surgery. Most are related to specimen extraction
sites, which are not relevant to incisional hernia
repairs.
We know from the laparoscopic literature that
port-site hernias increase with increasing size of
the fascial defect [3]. It is important to note that
the outer diameter of almost all trocars and cannulas is greater than the purported size (Tables
13.2 and 13.3). This should lead the surgeon to
be more cognizant of how he/she manages the
port site. It is commonly accepted that 15 mm
laparoscopic ports must be all closed. Most
advocate closure of 10 and 12 mm port sites,
especially if they are at higher risk for herniation, e.g., patients with thin abdominal wall. This
is also the recommendation by the European
Hernia Society [4]. Interestingly, port site closure has been associated with higher risk of portsite herniation in the morbidly obese undergoing
13 Postoperative Management (Routine andComplex Situations)
165
bariatric surgery [5]. Port-site closure for trocars
under 15 mm may not be necessary in this
population.
With laparoscopy, there is a tendency to skive
the trocar in the direction of the operative eld.
This may reduce the risk of incisional hernia.
Since that is not the technique recommended
with the robotic cannulas, the expectation is that
there is a higher risk of incisional hernia.
However, this has not yet been reported as a common complication in robotic surgery.
The reported robotic cannula-site hernia rate
requiring intervention is well under 0.5% for
general surgical procedures [6]. This rate may
be higher in patients who have already shown a
propensity for incisional hernia, though one
study did not show a difference in port-site hernia whether or not one had a past history of hernia [6]. The herniations can occur at 8 and
12mm ports, even if the port was closed at the
time of surgery. The lateral vs. midline placement of the port has also not been shown to be a
predictor of hernia development. Conceptually,
blunt obturators may cause less tissue injury
than the sharp, but there are currently no studies
to correlate port-site hernia rates between the
two obturator types. We know from the laparoscopic literature that bladeless and radially
dilating trocars have a lower rate of port-site
hernia than bladed trocars [3].
The median time to port-site hernia diagnosis
is within the rst 9months [6]. We know from
laparoscopic data that critical bowel obstruction
due to port-site hernias occurs within 21days of
surgery, whereas symptomatic non-obstructing
hernias tend to present later [5]. This is an important detail, as the differential diagnosis of any
postoperative nausea, vomiting, obstructive
symptoms, or port-site pain with erythema within
the rst 3weeks postoperatively must include a
port-site hernia.
Robotic arms may generate much more torque
at the abdominal wall than that seen with laparoscopy, especially if the cannulas are not optimally
positioned. In the case of incisional hernia
repairs, due to the necessary angulation toward
the anterior abdominal wall, one would expect
the amount of torque to be higher than average.
Thus, it is possible that the abdominal wall defect
caused by the robotic cannula is larger than
expected, resulting in a higher rate of port-site
hernia. To date, not enough data exists to support
these conjectures, but it is important to understand the physics of the robot on the abdominal
wall and be wary of related complications when
caring for patients postoperatively.
The Abdominal Wall
The torque on the abdominal wall during laparoscopic surgery is variable, dependent mostly on
the patient’s body habitus. It is most taxing in the
morbidly obese, with signicantly lower torque
and tension on the abdominal wall required for
thinner patients. In general, the trauma to the
abdominal wall is minimal during laparoscopic
surgery. During incisional hernia repair, the
angulation toward the anterior abdominal wall
can be quite acute, especially in the morbidly
obese. Nevertheless, the surgeon is able to feel
the amount of tension he/she is exerting. This
“interfering force” can often be positive feedback
from the patient’s abdomen, thus preventing the
surgeon from applying too much force during the
operation [7]. The less tension and force on the
abdominal wall, the less edema, ecchymoses, and
postoperative pain.
The torque on the abdominal wall during
robotic surgery is variable, dependent on the
operation, patient body habitus, and experience
and needs of the surgeon. If the cannulas are perfectly positioned, with the rotational axis of the
cannula centered at the fascia level, the expectation is that little torque will be exerted on the
abdominal wall. However this amount of torque
has not yet been quantied. It is important to
“burp” the trocars multiple times throughout the
procedure, to ensure that abnormal tension on the
abdominal wall is minimized. The result will be
less edema and pain at the surgical sites.
Given the stiffer robotic cannula and the
mechanical power of the arms, it is conceivable
that there is more transfer of force onto the
patient’s abdominal wall and less onto the instruments and the surgeon as compared to
166
S. Towgh and D. T. K. Huynh
laparoscopic surgery. This is one of the reasons
many prefer robotic approach for the morbidly
obese: it is physically less taxing on the surgeon
and the instruments, resulting in improved
manipulation at the tissue level [8].
Laparoscopic incisional hernia repair often
involves transfascial sutures with or without
other xation options, such as tackers.
Transfascial sutures have been implicated as an
independent risk factor for postoperative pain
and prolonged length of stay after hernia repair
[9]. The pain associated with these sutures is signicant and can be debilitating. The key is to prevent tightly knotting these sutures, as the patient
needs to be able to have a mobile abdominal wall,
and thus some freedom of movement despite the
placement of the mesh.
Postoperatively, patients may present with
point-tenderness at a single spot, associated with
the point of transfascial suture. This can be
treated with local anesthetic infusion at the fascia
level directly at that location. If periodic injections do not cure the chronic pain, then suture
removal should be performed. This can be performed with a simple cutdown over the area of
pain.
“Suture hernias” are a little known but difcult complication of transfascial sutures placed
too tightly or under tension [10]. They result in a
wide tear of the abdominal wall at the site of the
transfascial suture. The presentation is of pain,
bulging, and a new hernia, now lateral to the area
of the original repair. It is often at the edge of the
prior mesh repair. The patient may claim to have
felt an acute pull or tear over the area, often after
an activity that rapidly increases their abdominal
pressure. To repair, one will need to add a second
patch of mesh over this region, overlapping with
the rst repair. Prevention, via calculated suture
placement and gentle knot tying, is key to reduce
the risk of such complication.
When switching to robotic surgery, most studies show comparable or decreased postoperative
abdominal wall pain, with reduction in need for
opioid pain medication by as much as 30% [11,
12]. A signicant difference was seen for large
incisional hernias, requiring a transversus
abdominis release. When performed robotically,
these patients saw a signicant reduction in postoperative pain and hospital length of stay [12–
16]. It is no longer uncommon to see patients
discharged home on the same day or on postoperative day one following a large robotic incisional hernia repair or abdominal wall
reconstruction, whereas the typical postoperative
length of stay may range from 3 to 5 days for
patients undergoing open repair. Contributors
toward reducing postoperative pain after robotic
surgery may include minimizing incisions, reducing tension on the abdominal wall and minimizing use of transfascial sutures.
Though most modern studies for incisional
hernias show improved outcomes and reduced
pain control after robotic surgery, seromas and
other surgical site occurrences remain a problem
in up to half the patients [14, 16, 17]. This is a
higher level than that seen in laparoscopic surgery for incisional hernias. It is possible that the
reason for this is the extensive tissue plane dissection involved in the robotic approach.
The liberal use of drains can help reduce this
problem, especially for the larger abdominal wall
reconstructions. Many surgeons routinely use
drains in the soft tissue as well as overlying the
mesh. I do not place drains for the mesh, and
have not had any issues with seromas at the mesh
level. When placing drains, the key is to (a) skive
the drain to reduce direct communication with
your working space once the drain is removed,
and (b) minimize the skin incision made for the
drain exit. Though it is technically tricky, I use
the spear that comes with such drains. It allows
for easy exteriorization of the drain without digging a large tunnel.
Handling Abdominal Contents
The most dangerous risk of both laparoscopic
and robotic incisional hernia repair is intestinal
injury. The incidence may be up to 6% [2]. With
laparoscopic surgery, we have learned that the
use of electrocautery should be minimized, and
many also do not advocate use of ultrasonic
shears. This is also the recommendation from
major surgical societies [2, 18]. In these
13 Postoperative Management (Routine andComplex Situations)
167
situations, bowel injury may be occult or sealed
at the time of the operation, with presentation
only postoperatively.
The robotic approach adds an extra element of
risk for intestinal injury. As designed today, the
da Vinci robot does not offer tactile sensation.
Accidentally piercing a loop of intestine can
occur without any feedback from your instrument. This is most likely if the instrument is
moving outside your eld of view. Also, choice
of instrument can affect the risk of intestinal
injury. For example, the Prograsp™ instrument is
inappropriate during intestinal adhesiolysis, due
to its very strong grasp strength.
For both laparoscopic and robotic incisional
hernia repairs, the risk of intestinal injury is real
and can be missed intraoperatively. Thus, it is
imperative that there be a high suspicion for
missed injury with any aberrancy noted postoperatively. Similar to laparoscopic surgery, the risk
of intestinal injury during robotic surgery has
been associated with surgeon experience [19].
The highest rate has been reported in the gynecologic population, with 0.6% risk of intestinal
injury (range 0–6.25%) [20]. These numbers are
similar in the laparoscopic incisional hernia
repair literature [2].
Depending on the extent of intestinal injury,
most patients will present with signs and symptoms of intestinal leakage within the rst 3days
postoperatively. Thus, due diligence to work up
any unexpected nausea, vomiting, fever, abdominal pain, and/or hypotension, is warranted. In
some cases, a return to the operating room may
be the best next step, in order to minimize delay
in treatment. It is well appreciated that delay in
treatment of an abdominal catastrophe has a high
mortality rate.
Fortunately, if noted early, some intestinal
injuries may be treated with minimally invasive
approach [20]. Also, since robotic incisional hernia repair is often performed with the mesh
placed extraperitoneally, the risk of mesh infection is lower than with intraperitoneal mesh
placement, which is more commonly seen with
laparoscopic approach. However, if the mesh is
intraperitoneal, removal of the mesh at the time
of intestinal injury repair is mandated.
Other critical events have been reported intraoperatively which can affect the patient’s outcome after robotic surgery [10]. These include
malfunctions of the robotic system, inadvertent
injuries to other organs and vessels. In a review
of the FDA MAUDE database, between 2000 and
2013, 197 adverse events during a general surgery procedure were logged, of which 37 were
during hernia repair [21]. The majority were malfunctions of the robotic system. However, 28.4%
involved direct injury to the patient and 5.6%
resulted in patient death.
Mesh Placement
Mesh placement during laparoscopic surgery is
typically via intraperitoneal onlay mesh (IPOM).
This has proven to be safe and effective for the
most part, and is considered the most common
laparoscopic approach. However, with time, we
have noticed drawbacks to intraperitoneal mesh
placement. Mesh-related complications within
the rst 5years postoperatively can reach 3.7%
[22]. These include mesh-related intestinal
obstructions, perforations, stulas, and
infections.
With the increased penetrance of robotic surgery, we have moved away from the intraperitoneal mesh placement that was popularized with
laparoscopic incisional hernia repair. Many of us
agree that mesh-related complications, such as
ileus, intestinal obstruction, and stula, may be
reduced with the extraperitoneal mesh placement. The data is limited for directly measuring
the mesh-related complications after robotic surgery. However, it is conceivable that by reducing
the risk of mesh exposure to the intestinal contents, the risk of mesh-related intestinal complications and infections may also be reduced.
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Management ofAdverse Events
During Laparoscopic andRobotic
Hernia Repair
CiaraR.Huntington, JonathanD.Bouchez,
andDavidA.Iannitti
14
Introduction
Over 350,000 ventral hernia repairs are performed
annually each year in the United States, accounting for more than $3.2 billion in costs [1]. However,
when adverse events occur during or following
hernia repair, those costs increase dramatically,
and patient quality of life is directly impacted [2–
4]. Meticulous surgical technique and judgment is
necessary to avoid or reduce the risk of adverse
events during hernia repair. Every hernia surgeon
must know how to appropriately treat complications when they arise. Herein, this chapter details
the management of intraoperative and perioperative adverse events for the hernia surgeon.
Intraoperative Adverse Events
Incidence andCategorization
ofIntraoperative Adverse Events
The incidence of intraoperative complications
during laparoscopic or robotic ventral hernia
C. R. Huntington · J. D. Bouchez
Department of Surgery, Carolinas Medical Center,
Atrium Health, Charlotte, NC, USA
D. A. Iannitti (*)
Division of Hepatobiliary and Pancreatic Surgery,
Carolinas Medical Center, Atrium Health,
Charlotte, NC, USA
e-mail: David.iannitti@atriumhealth.org
repair has a direct impact on long-term patient
morbidity and mortality. As experience in laparoscopic surgery and subsequently robotic surgery
has increased, surgeon comfort with these
advanced techniques has increased. However,
intraoperative events remain a signicant concern during laparoscopic procedures despite progression of techniques [5]. Intraoperative events
in complex laparoscopic procedures are associated with near-doubling of local and general morbidity at 41.2 vs. 18.0% (p<0.001) and 32.9%
vs. 17.2% (p<0.001), respectively, for colorectal
resection [5]. Additionally, the occurrence of
major intraoperative events is associated with a
twofold increase in 30-day readmission, an
important metric in the era of outcome-based
reimbursement [6].
Intraoperative complications may be categorized by whether or not their occurrence is a
direct consequence of a surgeon’s performance.
The preoperative workup may help avoid or
reduce the risk of intraoperative medical adverse
events, such as cardiac arrhythmia or pulmonary
embolism. Additional medical concerns of operation include risks associated with anesthesia and
abdominal insufation. Of surgical intraoperative
adverse events, hernia surgeons are particularly
concerned with management of iatrogenic bowel
injury and enterotomy. The reality is that these
events can occur despite the best efforts of even
the most skilled surgeon.
© Springer International Publishing AG, part of Springer Nature 2018
K. A. LeBlanc (ed.), Laparoscopic and Robotic Incisional Hernia Repair,
https://doi.org/10.1007/978-3-319-90737-6_14
169